Denture stomatitis is a chronic inflammatory condition of the oral mucosa underlying complete or removable partial dentures. Causes of denture stomatitis include poor oral or denture hygiene, ill-fitting denture, or night-time denture wear with most cases being assocciated with Candida. Treatments for denture stomatitis include, anti-fungal treatment, denture cleaning and disinfection, natural remedies, microwave disinfection, and photodynamic therapy.
The aim of this review was to assess the comparative efficacy of interventions used for the treatment of denture stomatitis.
Methods
A protocol was registered with the PROSPERO database. Searches were undertaken in the Medline/PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Randomised controlled trials (RCTs) of denture stomatitis (DS) treatments verses placebo, no treatment or another active intervention published in English were considered. Three reviewers independently screened and selected studies extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2.0) with disagreements being resolved by discussion. The primary outcome was the clinical improvement in the clinical signs and symptoms of DS with mycological resolution of candida colony counts in colony forming units (CFUs) and side effects as secondary outcomes. A network meta-analysis (NMA) was performed, and interventions were ranked according to their effectiveness in the treatment of DS based on outcomes using surface under the cumulative ranking (SUCRA).
Results
- 35 studies met the inclusion criteria with 25 RCTs contributing to the meta-analysis.
- Duration on interventions ranged from 7 to 28 days with the evaluation periods ranging from 3 to 90 days.
- 20 RCTs were considered to be at high risk of bias, one at low risk and 4 to have some concerns.
- 15 RCTs were included in a network meta-analysis (NMA) for clinical improvement of denture stomatitis with significant clinical improvements being seen for; topical antifungal agents (TopAF); TopAF + systemic antifungal agents (SysAF); SysAF; photodynamic therapy and topical plant products (see table below).
| Interventions | SUCRA ranking | Relative risk (95%CI) |
| Topical antifungal agents (TopAF) | 1 (82.1) | 4.37 (2.15 to 8.90) * |
| TopAF + Systemic antifungal agents (SysAF) | 2 (77.5) | 4.25 (1.75 to 10.33) * |
| SysAF | 2 (77.5) | 4.25 (1.79 to 10.10) * |
| Photodynamic therapy | 4 (74.3) | 4.03 (1.81 to 8.98) * |
| Low power laser therapy | 5 (61.3) | 3.03 (0.83 to 11.09) |
| Topical plant products | 6 (61.2) | 3.40 (1.59 to 7.26) * |
| TopAF + placebo (PLA) | 7 (52.2) | 2.65 (0.14 to 49.42) |
| Occlusal splint | 8 (43.8) | 2.17 (0.85 to 5.53) |
| Topical antimicrobial agents (TopAM) | 9 (37.8) | 1.92 (0.63 to 5.82) |
| New denture | 10 (28.5) | 1.64 (0.59 to 4.50) |
| Tissue conditioner | 11 (22.4) | 1.46 (0.47 to 4.58) |
| Denture removal | 12 (20.2) | 1.17 (0.23 to 5.90) |
* Statistically significant
- 10 RCTs were included in a NMA for mycological resolution of denture stomatitis almost all interventions reached statistical significance with microware disinfection plus topical antifungals being the most effective (see table below).
| Interventions | SUCRA ranking | Relative risk (95%CI) |
| Microwave disinfection + TopAF | 1 (94.2) | 7.38 (2.75 to 19.81) * |
| Microwave disinfection | 2 (94) | 7.38 (2.75 to 19.81) * |
| TopAF | 3 (72.9) | 4.88 (1.92 to 12.42) * |
| Topical plant products | 4 (65) | 4.49 (1.70 to 11.82) * |
| SysAF + TopAM | 5 (57.5) | 3.85 (1.33 to 11.10) * |
| TopAM | 6 (44.7) | 3.39 (1.17 to 9.81) * |
| SysAF | 7 (43.3) | 3.37 (1.21 to 9.34) * |
| Photodynamic therapy (PDT) | 8 (36.1) | 2.93 (1.01 to 8.47) * |
| PDT + low power laser therapy | 9 (26.8) | 2.44 (0.81 to 7.32) |
| Tissue conditioner | 10 (11.5) | 1.47 (0.39 to 5.59) |
* Statistically significant
- 8 studies contributed to a NMA of side effects with topical antimicrobial agents being associated with the highest risk of side effects and topical plant products the lowest (see table below).
| Interventions | SUCRA ranking | Relative risk (95%CI) |
| Topical plant products | 1 (94.8) | 0.09 (0.00 to 4.16) |
| Systemic antifungal agents | 2 (68.9) | 0.89 (0.14 to 5.58) |
| Placebo | 3 (66.4) | Reference |
| Topical antimicrobial agents + plant products | 4 (32.6) | 7.60 (0.30 to 193.30) |
| Topical anti-fungals | 5 (29) | 5.30 (0.38 to 73.05) |
| Topical antimicrobial agents | 6 (8.4) | 20.90 (1.18 to 370.84) |
Conclusions
The authors concluded: –
….topical antifungals, microwave, and systemic antifungals are effective in the treatment of DS, but confidence in these findings is low because of the limited number of studies and a high risk of bias. Additional clinical trials are needed on photodynamic therapy, topical plant products, and topical antimicrobials.
Comments
The authors used a pre-registered protocol and searched a good range of databases. However, restricting inclusion to English language paper may have excluded some relevant studies. The included studies were published between 1972 and 2020. While a majority (15) of the 25 studies contributing to the meta-analysis were published after the publication of the first CONSORT (Consolidated Standards of Reporting Trials) statement in 1996 only one of the included studies was considered to be at low risk of bias.
15 trials were included in the NMA for clinical resolution which suggests that topical antifungals were the most effective and 10 trials for the efficacy of mycological resolution which suggested microwave disinfection together with topical antifungals was most effective. It should be noted that topical antifungals were the second worst performer in relation to side-effects but only 8 RCTs contributed to this analysis and confidence intervals were wide. While the findings suggest a hierarchy of treatment for denture stomatitis the low quality of the included studies and the small number of studies available for some interventions mean that the findings should be considered carefully. Future studies should be well conducted and reported with protocols being developed in line with SPIRIT Statement and reported following the CONSORT statement. Studies would also benefit from the use of common outcome measures as suggested by the authors of this review.
Links
Primary Paper.
Xin YH, Ying TJ, Syeed MS, Veettil SK, Menon RK. Comparative effectiveness of interventions for the treatment of denture stomatitis: A systematic review with network meta-analysis. J Prosthet Dent. 2023 Feb 28:S0022-3913(23)00019-7. doi: 10.1016/j.prosdent.2023.01.007. Epub ahead of print. PMID: 36863936.
Other references
Dental Elf – Denture Stomatitis Blogs
